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Effective July 15th, Health Services for Children with Special Needs (HSCSN) will implement Optum Financial/Optum Pay as the check payment vendor for provider electronic funds transfer (EFT). The details to the provider letter can be found in this document.

Appeals and Fair Hearings

Appeals and Fair Hearings

If you believe that services were unfairly denied, reduced, delayed or stopped, you have a right to file an Appeal with HSCSN and request a “Fair Hearing” with the District of Columbia Office of Administrative Hearings.

  • An Appeal is a formal request for HSCSN to review a decision whether or not to cover (pay for) a service that was requested for a enrollee.
  • The HSCSN Appeal process must be used before a Fair Hearing can be requested.
  • For questions about Appeals, please call the HSCSN Grievances and Appeals Hotline at (202) 495-7582.
  • An Appeal must be requested within 60 calendar days of the date the notice (letter) was sent.
  • A Fair Hearing request must be filed within 120 days of the Notification of Resolution of an Appeal.
  • Your provider or an authorized representative may request an Appeal or file for a Fair Hearing on your behalf with your written permission (consent).

Appeals

  • An Appeal of a denial, reduction, or termination of services must be submitted within 60 days of the date the notification (letter) was sent.
  • To file an Appeal with HSCSN, call the Grievance and Appeal Hotline at (202) 495-7582 or fax the request for an Appeal to (202) 635-5591 or mail the Appeal request to:

Health Services for Children with Special Needs, Inc.
ATTN: UM-Appeals
1101 Vermont Avenue NW, Suite 1200
Washington, D.C. 20005

  • If you call and give your Appeal over the phone, HSCSN will summarize your Appeal in a letter and send you the letter for you to sign. Be sure to read the letter carefully. You must sign the letter and return it to HSCSN to have an Appeal.
  • If services are being terminated (stopped) or reduced (decreased) and you want to continue receiving the services (benefit) during your Appeal, you must request the Appeal and Continuation of Benefits within 10 days of the date of the Notice of Action (letter notifying you of termination or reduction of services) or before the effective date of the termination or reduction of the service. The effective date is on the letter and is the date on which the services are intended to be stopped or reduced.
  • Your Appeal will be decided by HSCSN within 30 calendar days from the date your Appeal was received.
  • If HSCSN needs more time to get information and the District decides this would be best for you, or if you or your authorized representative request more time, HSCSN may increase the time for the Appeal decision by 14 calendar days. HSCSN must give you written notice of the extension.
  • You will receive written notice of HSCSN’s decision about your Appeal in the mail (Notification of Resolution of Appeal)./li>
  • If you are not happy with HSCSN’s decision about your Appeal you may request a Fair Hearing.

Expedited (Urgent) Appeals Process

If your Appeal is determined to be an emergency, HSCSN will give you a decision within 3 calendar days. An Appeal is considered urgent if it would be harmful or painful to you if you had to wait for the standard timeframe of the Appeal procedure.

All Appeals filed by enrollees with HIV/AIDS, behavioral illness or any other condition that needs attention right away, will be resolved and communicated back to the enrollee within 24 hours of filing the Appeal.

Fair Hearings

  • A Fair Hearing is heard by a judge in the Office of Administrative Hearings.
  • A Fair Hearing request must be filed within 120 days of the Notification of Resolution of an Appeal. 
  • A Fair Hearing can be requested if HSCSN does not follow its procedures for handling of Appeals.
  • Your provider or an authorized representative may file for a Fair Hearing on your behalf with your written permission (consent).
  • To request a Fair Hearing with the District of Columbia Office of Administrative Hearings please call or write (within 120 days from the date of HSCSN’s Notice of Resolution of an Appeal) to:

District of Columbia Office of  Administrative Hearings Clerk of the Court
441 4th St., NW, N450
Washington, D.C. 20001
Telephone Number: (202) 442-9094

  • You may receive help from HSCSN in filing your request for a Fair Hearing by calling (202) 495-7582. If you are not satisfied with the help given by HSCSN, you may contact the District’s Ombudsman Program at (202) 724-7491 and they will help you.
  • At the Fair Hearing, you may represent yourself. You may also have a lawyer, a relative, a friend or other person represent you. Your representative cannot be a District of Columbia government or HSCSN employee.
  • You may also qualify for free legal services from the following free legal service providers:
    • Columbus Community Legal Services, 3602 John McCormack Road, N.E., Washington, D.C., 20064. Phone: (202) 319-6788
    • Neighborhood Legal Services, 64 New York Ave. NE, Suite 180, Washington D.C. 20002. Phone: (202) 832-6577
    • Legal Aid Society, 1331 H St. NW, Room 350, Washington, D.C., 20005. Phone (202) 628-1161
    • Terris, Pravlik Millian, LLP, 1816 12th Street, NW, Suite 303, Washington, D.C., 20009. Phone (202) 682-2100 (applicable only for children from birth to 20 years of age)

Your Rights during the Grievances, Appeals and Fair Hearings Process

  • You have the right to a Fair Hearing. You may request a Fair Hearing from the Office of Administrative Hearings only after receiving notice from HSCSN regarding resolution of an Appeal. You must request the Fair Hearing no later than 120 days from the date of the HSCSN notice of resolution (letter).
  • You have a right to keep receiving a benefit (service) that HSCSN terminated (stopped) or reduced (decreased) while your Appeal or Fair Hearing is in review. To keep receiving services (continuation of benefits) during such a period, you must request Continuation of Benefits within 10 days of the notice (letter) or before the effective date of the termination or reduction.
  • You have the right to have someone from HSCSN help you through the Grievance and Appeals process.
  • You have a right to represent yourself or be represented by your family caregiver, lawyer, or other representative.
  • You have a right to have accommodations made for any special health care need you have.
  • You have a right to adequate TTY/TTD capabilities, and services for the visually impaired.
  • You have a right to adequate translation services and an interpreter.You have a right to see all documents related to the Grievance, Appeal or Fair Hearing.

If you have any questions about the Grievances and Appeals/Fair Hearings process, please call the Grievance and Appeal Hotline at (202) 495-7582.